Description
An ideal resource for any health care professional needing to learn or improve their skills—with simple, straightforward explanations of the hows and whys of documentation. It also keeps pace with the changes in Physical Therapy practice today, emphasizing the Patient/Client Management model. Section by section, exercise by exercise, the 4th Edition will help you to to write clear, concise, and correct patient care notes using a variety of tools, including SOAP notes.
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Kettenbach's (Saint Louis U., Missouri) revised edition of the 2004 Writing SOAP Notes, 3rd ed., will help new and experienced physical therapists develop skills in writing clear, concise, and defensible patient care notes. While retaining earlier worksheets and some material on SOAP note writing, the new edition emphasizes the Patient/Client Management note and processes of The Guide to Physical Therapy Practice, 2nd ed. (American Physical Therapy Association, 2003); it assumes readers have access to the 2003 text. Twenty- two chapters cover background information on note taking; documenting the examination, the evaluation, and the plan of care; the medical record; and applications of documental skills. Each chapter includes explanatory text and worksheets; answers are included in the back. The fourth edition contains new chapters on writing evaluation, overview and legal aspects of the medical record, reimbursement, and the future--documentation using the WHO's ICF model. No subject index. Annotation ©2009 Book News, Inc., Portland, OR (booknews.com)
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